Overview of Challenges

While the over-50 age cohort has accounted for at least 10% of reported case of AIDS since the beginning of the US epidemic, there remain several health and social policies that are responsible for the neglect of this population with respect to basic HIV/AIDS education and screening. Ageism and societal stereotypes form a culture of risk denial concerning the elderly among the general population as well as within the healthcare community.5 The proportion of older individuals infected with the human immunodeficiency virus (HIV) is rising. From 1991 to 1996, cases among those over 50 increased 22% compared with 9% among 13-49 year olds. Through June 2000, 81,163 cases of AIDS in individuals over age 50 were reported to the Centers for Disease Control (CDC). Over 10% of these cases involved women, 73% of whom were nonwhite.5

Sexual activity among older adults is dependent on gender preference, functional abilities, partner availability, and opportunityÑas with any other age group.2 Substance use is common in the over-50 group, and includes alcohol and illegal and prescription drugs. Our culture's generally pro-heterosexual bias often impedes reaching older homosexual and lesbian adults for both HIV prevention and healthcare interventions.3 Knowledge of one's HIV antibody status is fundamental to reducing transmission in this age group. Awareness that the older adult has the same risk behaviors as other age groups allows the older adult a quicker entry into the healthcare system. The earlier HIV is recognized in this population by professional healthcare and prevention programs the better, because age is a predictor of HIV progression.1

There is also a paucity if not a total lack of pharmicokinetics research related to HAART and this population.4 This may be changing because HAART toxicities and the "aging" of America will call attention to the phenomena of HIV as the "aging virus" and to the population of those infected who are over the age of 50.1

Healthcare Needs

Persons over 50 with HIV disease need and deserve culturally sensitive and competent care related to age, ethnicity, gender identification, gender preference, religious beliefs, etc.

Basic HIV prevention information needs to include how to use barrier precautions (condoms, dental damns, etc). Healthcare provision needs to be research-based and knowledgeable with respect to the aging process along with HIV pathogenesis, HAART pharmicokinetics, and co-morbid diseases, e.g., hypertension, diabetes, and coronary artery disease.4 The normal aging process can cause a negative nitrogen balance and loss of muscle mass; a decrease in organ system reserves; a decrease in immune system function; altered metabolic patterns that impact drug pharmicokinetics; increased risk of medication side effects; and increased prevalence of co-morbid diseases. Many older adults have a variety of healthcare providers, e.g., optometrists, podiatrists, dentists, and may be reluctant to disclose their HIV status,5 some because they do not like the medical establishment, others because they not want to out to children, grandchildren, insurance companies, or employers.

Many conditions that are commonplace in the over-50 age group mimic or parallel HIV symptoms and result in the older person being misdiagnosed and their HIV disease being overlooked. For example, menopausal symptoms such as fever and night sweats; diabetic neuropathy, which is similar to HIV neuropathy; and multifocal dementia, which mimics HIV dementia/toxoplasmosis.1

HIV may worsen age-related susceptibility to and morbidity from infections. In addition, the complications of a lifetime of poor health choices impact the course of HIV in the older adult. Those older than 60 at time of diagnosis have a shorter survival than younger patients and are usually diagnosed late in the course of their HIV infection, resulting in an AIDS diagnosis as the initial diagnosis. The data from the Italian Conversion Study reports a significant decreased median survival after seroconversion (7.9 years postseroconversion for patients aged 45-54 vs. 12.5 for those aged 15-24.) This cohort is also reported to be more likely to die within 1 month of AIDS diagnosis (13% vs. 6%) and more likely to be diagnosed with opportunistic infections (OI) at time of initial presentation.1

Age and HIV Pathogenesis

Thymic function, which decreases with age, is important in the quantitative CD4 response to antiretroviral therapy.5 Genetic aging (polymorphisms in chemokine receptors) also enhance progression of HIV-1 infection. CD4 cells decrease and CD8 cells increase the longer a person lives, so attention needs to be focused on the ratio between CD4 and CD8 cells to obtain a clearer view of HIV disease in the older adult.1 Cell-mediated response to vaccines and infections are lost over time in the older adult. Anergy testing is not recommended. Hormonal fluctuations in menopausal women may cause blips in the viral load of cervical/vaginal secretions. Insulin resistance, which is associated with aging, may impact HAART choices (as would other co-morbid conditions common to this population).4 Other common concerns include reactivation of a latent TB infection and reactivation of other dormant infections. HIV infection and many of the medication regimens exacerbate problems related to thermal stress that are already present in this population.5

Psychosocial and Medical Considerations

Many of those infected with HIV have significant histories of domestic and/or sexual violence. Aging caregivers, both infected and affected, are overwhelmed with familial care issues and may repeat learned negative-coping behaviors.5 This population is usually isolated and has little to no information on social/medical support systems. Older adults may perceive the disclosure of their seropositivity an insurmountable obstacle. Fear of rejection from grown children and loss of interaction with grandchildren may be added to fears about rejection and/or embarrassment connected with acknowledging life choices that have been hidden from family, friends, church, and work affiliations.2 Many older adults are self-medicating and use a myriad of home remedies and herbal supplements. These older adults may not disclose this information to caregivers because they do not perceive these treatments to be "medicine." Nutritional intake may be inadequate due to economic, social, and/or physiological issues related to age. Malnutrition may negatively impact medication adherence and definitely impacts medication efficacy.1,5

Sexual history taking is extremely important in this population. Caretakers should include questions related to partner preference, any pain/discomfort with intercourse, number of partners, and use of barrier precautions. If patients are celibate, they should be asked why and for how long they have abstained from sex.1,5

It is also necessary to assess substance use and abuse and to assess home and relationship safety. Co-morbid conditions that generate a range of prescriptions in addition to HIV medical regimens can create an adherence nightmare as well as a number of drug-drug interactions. Adherence initiatives that promote patient- provider communication, enhanced patient self-management, and reduced regimen complexity should be considered in this population.1,5

Suellen T. Cirelli, MSN ARNP ACRN, is Coordinator of Medical Outreach for Florida AIDS Education and Training Center (AETC) at the Help Understand and Guide Me Program (HUG Me Program), and is affiliated with the Howard Phillips Center for Children and Families, the Arnold Palmer Women's and Children's Hospital, Orlando Regional Healthcare; she is also an instructor at Florida Southern College School of Nursing and at the Valencia Institute of Continuing Healthcare Education.

The HUG Me Program/AETC can be reached at 85 West Miller St. Suite 203, Orlando Florida 32806. Phone: ext. 2239; fax: ; e-mail: <>.

References:

The following materials were consulted in the preparation of this article.

     1.   Butt A, Dascomb K, Desalvo K, Bazzano L, Kissinger P, et al. Human immunodeficiency virus infection in elderly patients. South Med J. 2001;94(4):.

     2.   Caliandro G, Hughes C. The experience of being a grandmother who is the primary caregiver for her HIV-positive grandchild. Nursing Res. 1998;47(2):.

     3.   Eliason G. AIDS and the Aging. Newsline: People with AIDS Coalition of New YorkÑAIDS and the Aging. New York, NY: PWACNY, Inc. January, 1996; 7-35.

     4.   Phair J. HIV and the Elderly. Presented at HIV Treatment 2000: Clinical Management Issues. Tucson, Arizona: November 30-December 3, 2000. Rush-Presbyterian St. Luke's Medical Center, Chicago, Illinois.

     5.   Nokes KM, editor. HIV and the Older Adult. Washington, DC: Taylor & Francis. 1996; 9-23, 25-31.

Additional Resources:

Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Facilities. Atlanta Ga.: CDC; 1994a;43(RR-3):1-21.

Durso S. Technological advances for improving medication adherence in the elderly. Annals of Long-Term Care: Clinical Care and Aging. 2001;9(4):43-48.

Garfield C, Spring C, and Ober D. Sometimes My Heart Goes Numb: Loving and Caring in a Time of AIDS. San Francisco, Ca: Jossey-Bass Publishers. 1995; 41-52.

National Association on HIV Over Fifty. The NAHOF Connection. Available online at <http://www.hivoverfifty.org>.

Phillips et al. J AIDS. 1991;4:970:5.

Swanson K. Nursing as informed caring for the well being of others. IMAGE: Journal of Nursing Scholarship. 1993;25(4):.

Viard JP, et al. Influence of age on CD4 cell recovery in human immunodeficiency virus-infected patients receiving highly active antiretroviral therapy: Evidence from the EuriSIDA study. J Inf Dis. 2001; 183:.

Wallace J, Paauw D, And Spach, D. HIV infection in older patients: When to expect the unexpected. Geriatrics. 1993;48(6):61-70.

Watson, J. Nursing: Human Science and Human Care. Norwalk, Ct: Appleton-Century-Crofts. 1985; 32-76.